Smoking and respiratory conditions in pregnancy: associations with adverse pregnancy outcomes

County-Level Structural Vulnerabilities in Maternal Health and Geographic Variation in Infant Mortality

OBJECTIVE

To evaluate whether community factors that differentially affect the health of pregnant people contribute to geographic differences in infant mortality across the US.

STUDY DESIGN

This retrospective cohort study sought to characterize the association of a novel composite measure of county-level maternal structural vulnerabilities, the Maternal Vulnerability Index (MVI), with risk of infant death. We evaluated 11 456 232 singleton infants born at 22 0 of 7 through 44 6 of 7 weeks' gestation from 2012 to 2014. Using county-level MVI, which ranges from 0 to 100, multivariable mixed effects logistic regression models quantified associations per 20-point increment in MVI, with odds of death clustered at the county level and adjusted for state, maternal, and infant covariates. Secondary analyses stratified by the social, physical, and health exposures that comprise the overall MVI score. Outcome was also stratified by cause of death.

RESULTS

Rates of death were higher among infants from counties with the greatest maternal vulnerability (0.62% in highest quintile vs 0.32% in lowest quintile, [P < .001]). Odds of death increased 6% per 20-point increment in MVI (aOR: 1.06, 95% CI 1.04, 1.07). The effect estimate was highest with theme of Mental Health and Substance Abse (aOR 1.08; 95% CI 1.06, 1.09). Increasing vulnerability was associated with 6 of 7 causes of death.

CONCLUSIONS

Community-level social, physical, and healthcare determinants indicative of maternal vulnerability may explain some of the geographic variation in infant death, regardless of cause of death. Interventions targeted to county-specific maternal vulnerabilities may reduce infant mortality.

Co-occurring obesity and smoking among U.S. women of reproductive age: Associations with educational attainment and health biomarkers and outcomes

INTRODUCTION

Obesity and smoking are independently associated with socioeconomic disadvantage and adverse health effects in women of reproductive age and their children, but little is known about co-occurring obesity and smoking. The purpose of this study was to investigate relationships between co-occurring obesity and smoking, socioeconomic status, and health biomarkers and outcomes in a nationally representative sample.

METHODS

Data from non-pregnant women of reproductive age were obtained from the U.S. National Health and Nutrition Examination Surveys reported between 2007 and 2010. Linear and logistic regressions were used to examine associations between obesity and smoking alone and in combination with educational attainment and a range of health biomarkers and outcomes.

RESULTS

Prevalence of co-occurring obesity and smoking was 8.1% (~4.1 million U.S. women of reproductive age) and increased as an inverse function of educational attainment, with the least educated women being 11.6 times more likely to be obese smokers than the most educated. Compared to women with neither condition, obese smokers had significantly poorer cardiovascular and glycemic biomarker profiles, and higher rates of menstrual irregularity, hysterectomy, oophorectomy, physical limitations, and depression. Obese smokers also had significantly worse high-density lipoprotein (HDL) cholesterol levels, physical mobility, and depression scores than those with obesity or smoking alone.

CONCLUSIONS

Co-occurring obesity and smoking is highly associated with low educational attainment, a marker of socioeconomic disadvantage, and a broad range of adverse health biomarkers and outcomes. Interventions specifically targeting co-occurring obesity and smoking are likely necessary in efforts to reduce health disparities among disadvantaged women and their children.

Social determinants and the classification of disease: descriptive epidemiology of selected socially mediated disease constellations

BACKGROUND

Most major diseases have important social determinants. In this context, classification of disease based on etiologic or anatomic criteria may be neither mutually exclusive nor optimal.

METHODS AND FINDINGS

Units of analysis comprised large metropolitan central and fringe metropolitan counties with reliable mortality rates--(n = 416). Participants included infants and adults ages 25 to 64 years with selected causes of death (1999 to 2006). Exposures included that residential segregation and race-specific social deprivation variables. Main outcome measures were obtained via principal components analyses with an orthogonal rotation to identify a common factor. To discern whether the common factor was socially mediated, negative binomial multiple regression models were developed for which the dependent variable was the common factor. Results showed that infant deaths, mortality from assault, and malignant neoplasm of the trachea, bronchus and lung formed a common factor for race-gender groups (black/white and men/women). Regression analyses showed statistically significant, positive associations between low socio-economic status for all race-gender groups and this common factor.

CONCLUSIONS

Between 1999 and 2006, deaths classified as "assault" and "lung cancer", as well as "infant mortality" formed a socially mediated factor detectable in population but not individual data. Despite limitations related to death certificate data, the results contribute important information to the formulation of several hypotheses: (a) disease classifications based on anatomic or etiologic criteria fail to account for social determinants; (b) social forces produce demographically and possibly geographically distinct population-based disease constellations; and (c) the individual components of population-based disease constellations (e.g., lung cancer) are phenotypically comparable from one population to another but genotypically different, in part, because of socially mediated epigenetic variations. Additional research may produce new taxonomies that unify social determinants with anatomic and/or etiologic determinants. This may lead to improved medical management of individuals and populations.